Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR REOPENING RECENT LAPAROTOMY

Professional

Both

$2,191.00

Service Code	HCPCS 49002
Min. Negotiated Rate	$621.32
Max. Negotiated Rate	$1,906.44
Rate for Payer: Aetna Commercial	$1,409.38
Rate for Payer: Aetna Medicare	$1,095.50
Rate for Payer: BCBS Complete	$652.39
Rate for Payer: BCN Commercial	$1,564.66
Rate for Payer: Cash Price	$1,752.80
Rate for Payer: Cash Price	$1,752.80
Rate for Payer: Mclaren Medicaid	$621.32
Rate for Payer: Meridian Medicaid	$652.39
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,643.25
Rate for Payer: Priority Health Choice Medicaid	$621.32
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,906.44
Rate for Payer: Priority Health Narrow/Tiered Network	$1,906.44
Rate for Payer: UHC Medicaid	$621.32
Rate for Payer: UHCCP Medicaid	$621.32

PR REPAIR ANAL FISTULA W/FIBRIN GLUE

Professional

Both

$351.00

Service Code	HCPCS 46706
Min. Negotiated Rate	$113.53
Max. Negotiated Rate	$334.93
Rate for Payer: Aetna Commercial	$238.77
Rate for Payer: Aetna Medicare	$175.50
Rate for Payer: BCBS Complete	$119.21
Rate for Payer: BCN Commercial	$274.89
Rate for Payer: Cash Price	$280.80
Rate for Payer: Cash Price	$280.80
Rate for Payer: Mclaren Medicaid	$113.53
Rate for Payer: Meridian Medicaid	$119.21
Rate for Payer: Opus (Opus Packaging Group) HMA	$263.25
Rate for Payer: Priority Health Choice Medicaid	$113.53
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$334.93
Rate for Payer: Priority Health Narrow/Tiered Network	$334.93
Rate for Payer: UHC Medicaid	$113.53
Rate for Payer: UHCCP Medicaid	$113.53

PR REPAIR ANORECTAL FISTULA PLUG

Professional

Both

$1,068.00

Service Code	HCPCS 46707
Min. Negotiated Rate	$327.38
Max. Negotiated Rate	$936.83
Rate for Payer: Aetna Commercial	$673.80
Rate for Payer: Aetna Medicare	$534.00
Rate for Payer: BCBS Complete	$343.75
Rate for Payer: BCN Commercial	$768.88
Rate for Payer: Cash Price	$854.40
Rate for Payer: Cash Price	$854.40
Rate for Payer: Mclaren Medicaid	$327.38
Rate for Payer: Meridian Medicaid	$343.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$801.00
Rate for Payer: Priority Health Choice Medicaid	$327.38
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$936.83
Rate for Payer: Priority Health Narrow/Tiered Network	$936.83
Rate for Payer: UHC Medicaid	$327.38
Rate for Payer: UHCCP Medicaid	$327.38

PR REPAIR BIFID EARLOBES - BILATERAL

Professional

Both

$1,391.00

Hospital Revenue Code	990
Min. Negotiated Rate	$556.40
Max. Negotiated Rate	$1,043.25
Rate for Payer: Aetna Medicare	$695.50
Rate for Payer: BCBS Complete	$556.40
Rate for Payer: Cash Price	$1,112.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,043.25

PR REPAIR BIFID EARLOBES - UNILATERAL

Professional

Both

$901.00

Hospital Revenue Code	990
Min. Negotiated Rate	$360.40
Max. Negotiated Rate	$675.75
Rate for Payer: Aetna Medicare	$450.50
Rate for Payer: BCBS Complete	$360.40
Rate for Payer: Cash Price	$720.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$675.75

PR REPAIR BLOOD VESSEL DIRECT HAND FINGER

Professional

Both

$1,394.00

Service Code	HCPCS 35207
Min. Negotiated Rate	$435.80
Max. Negotiated Rate	$1,231.16
Rate for Payer: Aetna Commercial	$1,002.58
Rate for Payer: Aetna Medicare	$697.00
Rate for Payer: BCBS Complete	$457.59
Rate for Payer: BCN Commercial	$1,144.86
Rate for Payer: Cash Price	$1,115.20
Rate for Payer: Cash Price	$1,115.20
Rate for Payer: Mclaren Medicaid	$435.80
Rate for Payer: Meridian Medicaid	$457.59
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,045.50
Rate for Payer: Priority Health Choice Medicaid	$435.80
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,231.16
Rate for Payer: Priority Health Narrow/Tiered Network	$1,231.16
Rate for Payer: UHC Medicaid	$435.80
Rate for Payer: UHCCP Medicaid	$435.80

PR REPAIR BLOOD VESSEL DIRECT INTRA-ABDOMINAL

Professional

Both

$5,204.00

Service Code	HCPCS 35221
Min. Negotiated Rate	$853.49
Max. Negotiated Rate	$3,903.00
Rate for Payer: Aetna Commercial	$1,976.34
Rate for Payer: Aetna Medicare	$2,602.00
Rate for Payer: BCBS Complete	$896.16
Rate for Payer: BCN Commercial	$2,165.72
Rate for Payer: Cash Price	$4,163.20
Rate for Payer: Cash Price	$4,163.20
Rate for Payer: Mclaren Medicaid	$853.49
Rate for Payer: Meridian Medicaid	$896.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,903.00
Rate for Payer: Priority Health Choice Medicaid	$853.49
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,328.96
Rate for Payer: Priority Health Narrow/Tiered Network	$2,328.96
Rate for Payer: UHC Medicaid	$853.49
Rate for Payer: UHCCP Medicaid	$853.49

PR REPAIR BLOOD VESSEL DIRECT LOWER EXTREMITY

Professional

Both

$2,740.00

Service Code	HCPCS 35226
Min. Negotiated Rate	$482.45
Max. Negotiated Rate	$2,055.00
Rate for Payer: Aetna Commercial	$1,116.75
Rate for Payer: Aetna Medicare	$1,370.00
Rate for Payer: BCBS Complete	$506.57
Rate for Payer: BCN Commercial	$1,214.57
Rate for Payer: Cash Price	$2,192.00
Rate for Payer: Cash Price	$2,192.00
Rate for Payer: Mclaren Medicaid	$482.45
Rate for Payer: Meridian Medicaid	$506.57
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,055.00
Rate for Payer: Priority Health Choice Medicaid	$482.45
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,306.12
Rate for Payer: Priority Health Narrow/Tiered Network	$1,306.12
Rate for Payer: UHC Medicaid	$482.45
Rate for Payer: UHCCP Medicaid	$482.45

PR REPAIR BLOOD VESSEL DIRECT NECK

Professional

Both

$4,367.00

Service Code	HCPCS 35201
Min. Negotiated Rate	$539.32
Max. Negotiated Rate	$3,275.25
Rate for Payer: Aetna Commercial	$1,265.63
Rate for Payer: Aetna Medicare	$2,183.50
Rate for Payer: BCBS Complete	$566.29
Rate for Payer: BCN Commercial	$1,365.46
Rate for Payer: Cash Price	$3,493.60
Rate for Payer: Cash Price	$3,493.60
Rate for Payer: Mclaren Medicaid	$539.32
Rate for Payer: Meridian Medicaid	$566.29
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,275.25
Rate for Payer: Priority Health Choice Medicaid	$539.32
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,468.38
Rate for Payer: Priority Health Narrow/Tiered Network	$1,468.38
Rate for Payer: UHC Medicaid	$539.32
Rate for Payer: UHCCP Medicaid	$539.32

PR REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY

Professional

Both

$2,874.00

Service Code	HCPCS 35206
Min. Negotiated Rate	$461.78
Max. Negotiated Rate	$2,155.50
Rate for Payer: Aetna Commercial	$1,048.65
Rate for Payer: Aetna Medicare	$1,437.00
Rate for Payer: BCBS Complete	$484.87
Rate for Payer: BCN Commercial	$1,177.23
Rate for Payer: Cash Price	$2,299.20
Rate for Payer: Cash Price	$2,299.20
Rate for Payer: Mclaren Medicaid	$461.78
Rate for Payer: Meridian Medicaid	$484.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,155.50
Rate for Payer: Priority Health Choice Medicaid	$461.78
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,265.96
Rate for Payer: Priority Health Narrow/Tiered Network	$1,265.96
Rate for Payer: UHC Medicaid	$461.78
Rate for Payer: UHCCP Medicaid	$461.78

PR REPAIR BLOOD VESSEL VEIN GRAFT INTRA-ABDOMINAL

Professional

Both

$3,954.00

Service Code	HCPCS 35251
Min. Negotiated Rate	$998.33
Max. Negotiated Rate	$2,965.50
Rate for Payer: Aetna Commercial	$2,327.60
Rate for Payer: Aetna Medicare	$1,977.00
Rate for Payer: BCBS Complete	$1,048.25
Rate for Payer: BCN Commercial	$2,542.19
Rate for Payer: Cash Price	$3,163.20
Rate for Payer: Cash Price	$3,163.20
Rate for Payer: Mclaren Medicaid	$998.33
Rate for Payer: Meridian Medicaid	$1,048.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,965.50
Rate for Payer: Priority Health Choice Medicaid	$998.33
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,733.81
Rate for Payer: Priority Health Narrow/Tiered Network	$2,733.81
Rate for Payer: UHC Medicaid	$998.33
Rate for Payer: UHCCP Medicaid	$998.33

PR REPAIR BLOOD VESSEL VEIN GRAFT LOWER EXTREMITY

Professional

Both

$4,712.00

Service Code	HCPCS 35256
Min. Negotiated Rate	$591.50
Max. Negotiated Rate	$3,534.00
Rate for Payer: Aetna Commercial	$1,380.04
Rate for Payer: Aetna Medicare	$2,356.00
Rate for Payer: BCBS Complete	$621.08
Rate for Payer: BCN Commercial	$1,494.94
Rate for Payer: Cash Price	$3,769.60
Rate for Payer: Cash Price	$3,769.60
Rate for Payer: Mclaren Medicaid	$591.50
Rate for Payer: Meridian Medicaid	$621.08
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,534.00
Rate for Payer: Priority Health Choice Medicaid	$591.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,607.61
Rate for Payer: Priority Health Narrow/Tiered Network	$1,607.61
Rate for Payer: UHC Medicaid	$591.50
Rate for Payer: UHCCP Medicaid	$591.50

PR REPAIR BLOOD VESSEL W/GRAFT OTHER/THAN VEIN NECK

Professional

Both

$4,833.00

Service Code	HCPCS 35261
Min. Negotiated Rate	$572.33
Max. Negotiated Rate	$3,624.75
Rate for Payer: Aetna Commercial	$1,315.04
Rate for Payer: Aetna Medicare	$2,416.50
Rate for Payer: BCBS Complete	$600.95
Rate for Payer: BCN Commercial	$1,438.67
Rate for Payer: Cash Price	$3,866.40
Rate for Payer: Cash Price	$3,866.40
Rate for Payer: Mclaren Medicaid	$572.33
Rate for Payer: Meridian Medicaid	$600.95
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,624.75
Rate for Payer: Priority Health Choice Medicaid	$572.33
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,547.10
Rate for Payer: Priority Health Narrow/Tiered Network	$1,547.10
Rate for Payer: UHC Medicaid	$572.33
Rate for Payer: UHCCP Medicaid	$572.33

PR REPAIR BLOOD VESSEL W/VEIN GRAFT NECK

Professional

Both

$1,953.00

Service Code	HCPCS 35231
Min. Negotiated Rate	$692.04
Max. Negotiated Rate	$1,998.54
Rate for Payer: Aetna Commercial	$1,673.50
Rate for Payer: Aetna Medicare	$976.50
Rate for Payer: BCBS Complete	$726.64
Rate for Payer: BCN Commercial	$1,858.46
Rate for Payer: Cash Price	$1,562.40
Rate for Payer: Cash Price	$1,562.40
Rate for Payer: Mclaren Medicaid	$692.04
Rate for Payer: Meridian Medicaid	$726.64
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,464.75
Rate for Payer: Priority Health Choice Medicaid	$692.04
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,998.54
Rate for Payer: Priority Health Narrow/Tiered Network	$1,998.54
Rate for Payer: UHC Medicaid	$692.04
Rate for Payer: UHCCP Medicaid	$692.04

PR REPAIR BLOOD VESSEL W/VEIN GRAFT UPPER EXTREMITY

Professional

Both

$3,809.00

Service Code	HCPCS 35236
Min. Negotiated Rate	$584.90
Max. Negotiated Rate	$2,856.75
Rate for Payer: Aetna Commercial	$1,348.22
Rate for Payer: Aetna Medicare	$1,904.50
Rate for Payer: BCBS Complete	$614.14
Rate for Payer: BCN Commercial	$1,486.97
Rate for Payer: Cash Price	$3,047.20
Rate for Payer: Cash Price	$3,047.20
Rate for Payer: Mclaren Medicaid	$584.90
Rate for Payer: Meridian Medicaid	$614.14
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,856.75
Rate for Payer: Priority Health Choice Medicaid	$584.90
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,599.06
Rate for Payer: Priority Health Narrow/Tiered Network	$1,599.06
Rate for Payer: UHC Medicaid	$584.90
Rate for Payer: UHCCP Medicaid	$584.90

PR REPAIR BROW PTOSIS

Professional

Both

$1,366.00

Service Code	HCPCS 67900
Min. Negotiated Rate	$276.05
Max. Negotiated Rate	$1,024.50
Rate for Payer: Aetna Commercial	$658.86
Rate for Payer: Aetna Medicare	$683.00
Rate for Payer: BCBS Complete	$289.85
Rate for Payer: BCN Commercial	$749.46
Rate for Payer: Cash Price	$1,092.80
Rate for Payer: Cash Price	$1,092.80
Rate for Payer: Mclaren Medicaid	$276.05
Rate for Payer: Meridian Medicaid	$289.85
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,024.50
Rate for Payer: Priority Health Choice Medicaid	$276.05
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$877.87
Rate for Payer: Priority Health Narrow/Tiered Network	$877.87
Rate for Payer: UHC Medicaid	$276.05
Rate for Payer: UHCCP Medicaid	$276.05

PR REPAIR CARDIAC WOUND W/CARDIOPULMONARY BYPASS

Professional

Both

$7,917.00

Service Code	HCPCS 33305
Min. Negotiated Rate	$2,402.64
Max. Negotiated Rate	$6,438.50
Rate for Payer: Aetna Commercial	$5,503.81
Rate for Payer: Aetna Medicare	$3,958.50
Rate for Payer: BCBS Complete	$2,522.77
Rate for Payer: BCN Commercial	$5,987.23
Rate for Payer: Cash Price	$6,333.60
Rate for Payer: Cash Price	$6,333.60
Rate for Payer: Mclaren Medicaid	$2,402.64
Rate for Payer: Meridian Medicaid	$2,522.77
Rate for Payer: Opus (Opus Packaging Group) HMA	$5,937.75
Rate for Payer: Priority Health Choice Medicaid	$2,402.64
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$6,438.50
Rate for Payer: Priority Health Narrow/Tiered Network	$6,438.50
Rate for Payer: UHC Medicaid	$2,402.64
Rate for Payer: UHCCP Medicaid	$2,402.64

PR REPAIR CARDIAC WOUND W/O BYPASS

Professional

Both

$4,735.00

Service Code	HCPCS 33300
Min. Negotiated Rate	$1,446.91
Max. Negotiated Rate	$3,864.82
Rate for Payer: Aetna Commercial	$3,287.49
Rate for Payer: Aetna Medicare	$2,367.50
Rate for Payer: BCBS Complete	$1,519.26
Rate for Payer: BCN Commercial	$3,593.92
Rate for Payer: Cash Price	$3,788.00
Rate for Payer: Cash Price	$3,788.00
Rate for Payer: Mclaren Medicaid	$1,446.91
Rate for Payer: Meridian Medicaid	$1,519.26
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,551.25
Rate for Payer: Priority Health Choice Medicaid	$1,446.91
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$3,864.82
Rate for Payer: Priority Health Narrow/Tiered Network	$3,864.82
Rate for Payer: UHC Medicaid	$1,446.91
Rate for Payer: UHCCP Medicaid	$1,446.91

PR REPAIR CHOANAL ATRESIA INTRANASAL

Professional

Both

$1,264.00

Service Code	HCPCS 30540
Min. Negotiated Rate	$428.98
Max. Negotiated Rate	$1,104.52
Rate for Payer: Aetna Commercial	$932.51
Rate for Payer: Aetna Medicare	$632.00
Rate for Payer: BCBS Complete	$450.43
Rate for Payer: BCN Commercial	$1,104.52
Rate for Payer: Cash Price	$1,011.20
Rate for Payer: Cash Price	$1,011.20
Rate for Payer: Mclaren Medicaid	$428.98
Rate for Payer: Meridian Medicaid	$450.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$948.00
Rate for Payer: Priority Health Choice Medicaid	$428.98
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,040.14
Rate for Payer: Priority Health Narrow/Tiered Network	$1,040.14
Rate for Payer: UHC Medicaid	$428.98
Rate for Payer: UHCCP Medicaid	$428.98

PR REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM

Professional

Both

$956.00

Service Code	HCPCS 13151
Min. Negotiated Rate	$148.67
Max. Negotiated Rate	$717.00
Rate for Payer: Aetna Commercial	$299.73
Rate for Payer: Aetna Medicare	$478.00
Rate for Payer: BCBS Complete	$156.10
Rate for Payer: BCN Commercial	$415.81
Rate for Payer: Cash Price	$764.80
Rate for Payer: Cash Price	$764.80
Rate for Payer: Mclaren Medicaid	$148.67
Rate for Payer: Meridian Medicaid	$156.10
Rate for Payer: Opus (Opus Packaging Group) HMA	$717.00
Rate for Payer: Priority Health Choice Medicaid	$148.67
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$380.57
Rate for Payer: Priority Health Narrow/Tiered Network	$380.57
Rate for Payer: UHC Medicaid	$148.67
Rate for Payer: UHCCP Medicaid	$148.67

PR REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM

Professional

Both

$1,269.00

Service Code	HCPCS 13152
Min. Negotiated Rate	$177.64
Max. Negotiated Rate	$951.75
Rate for Payer: Aetna Commercial	$361.80
Rate for Payer: Aetna Medicare	$634.50
Rate for Payer: BCBS Complete	$186.52
Rate for Payer: BCN Commercial	$499.48
Rate for Payer: Cash Price	$1,015.20
Rate for Payer: Cash Price	$1,015.20
Rate for Payer: Mclaren Medicaid	$177.64
Rate for Payer: Meridian Medicaid	$186.52
Rate for Payer: Opus (Opus Packaging Group) HMA	$951.75
Rate for Payer: Priority Health Choice Medicaid	$177.64
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$457.16
Rate for Payer: Priority Health Narrow/Tiered Network	$457.16
Rate for Payer: UHC Medicaid	$177.64
Rate for Payer: UHCCP Medicaid	$177.64

PR REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM

Professional

Both

$623.00

Service Code	HCPCS 13131
Min. Negotiated Rate	$130.14
Max. Negotiated Rate	$467.25
Rate for Payer: Aetna Commercial	$260.73
Rate for Payer: Aetna Medicare	$311.50
Rate for Payer: BCBS Complete	$136.65
Rate for Payer: BCN Commercial	$362.53
Rate for Payer: Cash Price	$498.40
Rate for Payer: Cash Price	$498.40
Rate for Payer: Mclaren Medicaid	$130.14
Rate for Payer: Meridian Medicaid	$136.65
Rate for Payer: Opus (Opus Packaging Group) HMA	$467.25
Rate for Payer: Priority Health Choice Medicaid	$130.14
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$331.81
Rate for Payer: Priority Health Narrow/Tiered Network	$331.81
Rate for Payer: UHC Medicaid	$130.14
Rate for Payer: UHCCP Medicaid	$130.14

PR REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM

Professional

Both

$1,345.00

Service Code	HCPCS 13132
Min. Negotiated Rate	$160.18
Max. Negotiated Rate	$1,008.75
Rate for Payer: Aetna Commercial	$324.96
Rate for Payer: Aetna Medicare	$672.50
Rate for Payer: BCBS Complete	$168.19
Rate for Payer: BCN Commercial	$451.17
Rate for Payer: Cash Price	$1,076.00
Rate for Payer: Cash Price	$1,076.00
Rate for Payer: Mclaren Medicaid	$160.18
Rate for Payer: Meridian Medicaid	$168.19
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,008.75
Rate for Payer: Priority Health Choice Medicaid	$160.18
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$412.94
Rate for Payer: Priority Health Narrow/Tiered Network	$412.94
Rate for Payer: UHC Medicaid	$160.18
Rate for Payer: UHCCP Medicaid	$160.18

PR REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<

Professional

Both

$420.00

Service Code	HCPCS 13133
Min. Negotiated Rate	$65.18
Max. Negotiated Rate	$315.00
Rate for Payer: Aetna Commercial	$136.49
Rate for Payer: Aetna Medicare	$210.00
Rate for Payer: BCBS Complete	$68.44
Rate for Payer: BCN Commercial	$185.75
Rate for Payer: Cash Price	$336.00
Rate for Payer: Cash Price	$336.00
Rate for Payer: Mclaren Medicaid	$65.18
Rate for Payer: Meridian Medicaid	$68.44
Rate for Payer: Opus (Opus Packaging Group) HMA	$315.00
Rate for Payer: Priority Health Choice Medicaid	$65.18
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$170.00
Rate for Payer: Priority Health Narrow/Tiered Network	$170.00
Rate for Payer: UHC Medicaid	$65.18
Rate for Payer: UHCCP Medicaid	$65.18

PR REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM

Professional

Both

$563.00

Service Code	HCPCS 13120
Min. Negotiated Rate	$126.52
Max. Negotiated Rate	$422.25
Rate for Payer: Aetna Commercial	$250.47
Rate for Payer: Aetna Medicare	$281.50
Rate for Payer: BCBS Complete	$132.85
Rate for Payer: BCN Commercial	$345.10
Rate for Payer: Cash Price	$450.40
Rate for Payer: Cash Price	$450.40
Rate for Payer: Mclaren Medicaid	$126.52
Rate for Payer: Meridian Medicaid	$132.85
Rate for Payer: Opus (Opus Packaging Group) HMA	$422.25
Rate for Payer: Priority Health Choice Medicaid	$126.52
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$315.85
Rate for Payer: Priority Health Narrow/Tiered Network	$315.85
Rate for Payer: UHC Medicaid	$126.52
Rate for Payer: UHCCP Medicaid	$126.52

Know your out-of-pocket cost for care.

All Charges